DSM 5 What AALs and GALs Need to Know Norma Villanueva, LCSW, DCSW Modern View Clinical & Forensic...
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Transcript of DSM 5 What AALs and GALs Need to Know Norma Villanueva, LCSW, DCSW Modern View Clinical & Forensic...
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DSM 5 What AALs and GALs
Need to Know
Norma Villanueva, LCSW, DCSW
Modern View Clinical & Forensic [email protected]
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Multiaxial to Single Axis• Perhaps the most significant change in the DSM-5 was the return to a single-
axis diagnosis First, the separation of personality disorders to Axis II under DSM-IV gave these disorders undeserved status and the misguided belief that they were largely untreatable (Good, 2012; Krueger & Eaton, 2010). Clients who met the criteria for an Axis II diagnosis may now find it easier to navigate mental health treatment.
• Medical conditions are no longer listed on a separate axis (Axis III in DSM-IV). Thus, they will likely take a more significant role in mental health diagnosis.
• Psychosocial and environmental stressors, will be listed alongside mental disorders and physical health issues. In fact, DSM-5 has increased the number of “V codes” (Z codes in ICD-10), which are considered nondisordered conditions that sometimes are the focus of treatment and often are reflective of a host of psychosocial and environmental issues.
• As for the GAF score, previously on Axis V of DSM-IV, the APA intended to replace this historically unreliable tool with a different scaling assessment altogether.
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Systematic Changes
CHILDRENFAMLIESCOMMUNITY
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Case Example
• What the child wants . . .
• What the child needs . . .
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Case – First Phase
Full Adversary hearingMH Factors Parent Child – Outcry Family Dynamics nuclear extended
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Dynamics – Hints & Initial View
• The FIRST view of POSSIBLE mental health factors and family Dynamics is:
• Removal Affidavit
• Determination for FBSS
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Case – First Phase
Full Adversary hearing
MH Factors Parent Child – Outcry Family Dynamics nuclear extended
Service Plan Filed (45 days)
Services: How determined Therapy vs Eval Causal Factors vs Behavior
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Case – First Phase
Full Adversary hearing
MH Factors Parent Child – Outcry Family Dynamics nuclear extended
Service Plan Filed (45 days)
Services: How determined Therapy vs Eval Causal Factors vs Behavior
Status Hearing (60 days)
Diagnosis School Adjustment Outcry
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Comparative Example
Children Parents
Transparency
TherapyStyle
Visitation
Re-victimization
Triggers
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Case – Second Phase
First Permanency Hearing (180 days)Diagnosis Driven Therapy Risk Targeted Parent Child
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Risk• 78.3% Perpetrator is parent
• Child Vulnerability• Home & Social Environment• Caregiver Capability• Quality of Care• Maltreatment Pattern• Response to CPS• Protective Capacities
• 25.5% Turnover rate – case workers
2013 TDFPS-CPS Data Book
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Case – Second Phase
First Permanency Hearing (180 days)
Diagnosis Driven Therapy Risk Targeted Parent Child
Second Permanency Hearing (300 days)
Progress: How determined Behaviors Symptoms Notes
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Case – Second Phase
First Permanency Hearing (180 days)
Diagnosis Driven Therapy Risk Targeted Parent Child
Second Permanency Hearing (300 days)
Progress: How determined Behaviors Symptoms Notes
Trial/Final Order
Resolution of Risk Factors Adult Child Systemic-Family
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Case Example
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Diagnosis• Criterion for Clinical Significance
• WHO & DSM 5 Task force: distinguish between disability and mental disorder.
• Separate normal from pathological symptoms
• Function: “the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning”
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Nonaxial Format
• Axis I, II & III: Primary Diagnosis, and others in order of significance
• Axis IV replaced by V codes Z codes• Only if focus of treatment
• Axis V replaced by self report measures if utilized
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Work Toward Accurate Diagnosis
Level of Functioning in Major Roles
Self
Repo
rt D
espa
ir &
Sx
Seve
rity
Presenting Symptoms
Assess level of
functioning
Self report distress &
Impairment
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DSM 5
Biological Basis
Function
ICD-10
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Diagnosis
• Thorough Psychosocial History• Mental Status Exam
• History: Presenting Problem, specific symptoms, complaints• Identify duration and severity of symptoms• Functioning in major roles, ADL’s
• Mental Health History• Relevant medical history• Family History: MH, stressors• Social History: school/work, social/community• Diagnosis + specifiers
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Trauma & Stressor Related Disorders
• New category1
• Includes Adjustment disorders2
• New criteria3
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Trauma & Stressor related Disorders• PTSD: Changed definition of traumatic event
Eliminated criterion of how person responds to trauma• Exposure to actual or threatened a)death, b) serious injury, c)
sexual violation, in 1 or more of the following ways• Directly experiencing• Witnessing, in person, as they occur to others• Learning event occurred to a close family member or friend;
actual or threatened death must have been violent or accidental
• Experiencing repeated or extreme exposure to aversive details of traumatic events (not electronic media, tv, movies unless work related)
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Trauma & Stress Related Disorder: Clusters and Subtypes
4 Symptom Clusters• Intrusion• Avoidance• Negative alterations in cognition and mood• Marked alterations in arousal and reactivity
Different SubtypesEliminating Acute versus chronicAddition of Preschool subtypeAddition of Dissociative Subtype
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Trauma & Stress Related Disorder: Diagnostic CriteriaA. StressorB. 1 or more intrusion symptomsC. 1 or more avoidance of stimuli D. Negative alterations in cognition and mood (2 new)E. Marked altercations in arousal and reactivity
2 or more
Persistent, distorted blame of self or others about the cause or consequences of the traumatic event(s)
Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame)
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PTSD in Preschool Children
The first developmental subtype of a diagnosisCriterion Deleted: reaction to event, inability to recall, foreshortened futureIntrusion Sxs: Intrusive thoughts + neutral reactionAvoidance Sxs: cognition & mood alterations 1 symptom in avoidance or cognitive/mood Diminished interest = constricted play Detachment – behaviorally social withdrawalIncreased Arousal: addition of extreme temper tantrums.
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Neurodevelopmental Disorders
• IQ no longer criteria• <70 understood1
• Asperger’s in Autism spectrum2
• Variation in personality factors, IQ, and Sx severity
3
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Neurodevelopmental cont.
Diagnostic criteria: must assess cognitive capacity & adaptive functioning – determines Severity. Domains reduced from 3 to 2 • Social/communication deficits• Fixed Interests/repetitive behaviors• Merged Communication & Social interaction• Require 2 versus 3 behavioral markers• Onset: early childhood• Categorize by need for support• Removed language delay criterion
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ADHD
• Age of onset: prior to 12 + symptoms1
• 4 Subtypes2
• Requires 2 different informants3
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ADHD cont. • Subtypes: Combined,
Primarily Inattentive, Inattentive, Predominantly hyperactive/impulsive
• Criterion items are applied across the lifespan• Cross-Situational requirement strengthened to several
symptoms in each setting • Adult Symptom threshold reflects
significant impairment
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Specific Learning Disorders
• Reading, Writing, Math & Written expression combined
1
• R/O other disorders2
• Specific topic characteristics3
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Specific Learning Disorders cont.Specific Criteria for each: Can be combined• Reading: accuracy, rate, comprehension
Writing: accuracy of spelling, grammar & punctuation, legible handwriting, clarity of written expression Math: memorizing facts, accurate calculations, effective math reasoning. Written Expression: spelling, grammar, punctuation, clarity, organization
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Disruptive, Impulse-Control & Conduct Disorders
• Problems in emotional & behavioral self control symptoms
1
• Antisocial personality has dual listing2
• ADHD often comorbid with this diagnostic group.3